Working Towards Eliminating Surgical Site Infections

In working within the parameters of the SaferHealth Care Now bundle what have we within Sunrise been able to do to increase patients safety. By looking at indicators of infection we have been able to set up improvement projects to work towards a goal of zero clean surgical site infections. This session is to describe three of these improvement projects.

3.
Disclosure of Commercial Support
• This program has received in-kind support from [3M Canada] in the form of
[Educational training and warming equipment for trial]
• This program has received in-kind support from [Convatec] in the form of
[Educational training and two boxes of dressings for the trial]
Potential for Conflict(s) of Interest:
• [3M Canada and Convatec][developed/licenses/distributes/benefits from the
sale of] a product that will be discussed in this program: [Bear Hugger Warmers
and AQUACEL Surgical Dressings]

4.
Mitigating Potential Bias
• No financial incentive has been provided to either of the presenters. Only the
equipment or supplies used during the trial were provided to the health region by
either company. Contracts are in place to purchase any supplies found beneficial
after the trials ended.

5.
Who are we?
•We are a medium sized
health provider in Eastern
Saskatchewan.
•We service a population of
approximately 60,000 people
within the health region.
•We also provide surgical
services to a large area of
Western Manitoba.

6.
Why did Sunrise undertake this the Surgical
Site Infection (SSI) project
• We set out to reduce the issues
of time and suffering that
patients endure with a post
surgical infection.
• As well we wanted to look at
ways to reduce the unnecessary
use of health region resources to
treat people who develop a
Surgical Site Infections by
stopping them from occurring.

7.
How do you Identify the issues?
• We used the Canadian Patient Safety Institute SSI bundle.
• SSI indicators that were being used to identify infections Provincially,
Nationally and Internationally.
• Set up surveillance standards based on the criteria found in this
research.
• Talked with Staff and Physicians.

8.
Where did we begin?
• We picked the two high risk surgeries
noted in the literature that we
perform. Colorectal surgery and
Caesarian Sections.
• We did a 6 month retrospective data
analysis of all of these surgeries from
2010 so that we could have a baseline
to compare our ongoing surgical data.
• We began monthly auditing of all
cases in these two surgical categories.

9.
What did we find?
• We found trends that needed work:
• Inter-operative temperatures were being
recorded infrequently and many of our
patients were hypothermic after surgery
• Rates of infection were higher in our
clean (little or no bacterial contamination)
surgical cases than our dirty (Moderate to
High contamination ) surgical cases
• We rarely gave patients prophylactic
antibiotics within the hour prior to the
initial cut being performed

10.
What did this lead us to do?
• We first focused on our temperature
readings
• We instituted a policy that stated any
surgery over 30 minutes would require an
inter-operative temperature to be taken.
• We provided the surgical team with
esophageal temperature probes
• With the data from these successes we
were then able to assess that
approximately 20-25 percent of our patients
were hypothermic in any given quarter of
the year.

11.
• We then looked at what we were
doing to keep these patients
warm
• We gave warmed fluids
• Covered them with warmed
blankets
• The temperature of the theaters
is very difficult to regulate so it
tends to vary through out the
year depending on the external
temperature
• We had a warming blanket
placed on the table under the
patient’s back

12.
• None of these interventions was
enough to stop 20-25% of our
patient population from coming out
of the theater cold
• We looked at what other systems
were available to help us keep the
patients warm
• We found that the current company
whose equipment we had in the
theater made a total body warming
device “Bear Paws units”
• We decided to trial it to see what
kind of difference it would make
25
75
Hypothermic Patients
Throughout the Surgical
Procedure
Hypothermic

13.
• We ran a trial on 30
clients
• We used our normal
temperature monitoring
protocol on all of these
clients
• These clients could be
warmed prior to surgery,
while surgery occurred
and post surgery

14.
• What we found was that 90% of
clients maintained normal body
temperature 36-38 degrees
• Of the 10% that did not maintain
normal body temperature only
one client was hypothermic
through out the inter-operative
period
• All clients (100%) prior to
leaving recovery had returned to
the normal body temperature
range
10
90
Normothermia during the Surgical
Procedure
Hypothermia
Normothermic

15.
Antibiotics within 60 minutes
• We also focused in on timely
antibiotic administration
• This was noted to be an issue
and was the focus of one of our
first Mistake Proofing Projects
• What was found was that we
were providing antibiotic
prophylaxis to our surgical
patients within 60 minutes to
less than 30% of our patients
30
70
Prophylactic Antibiotics
Within 60
Minutes
Outside 60
Minutes

16.
Why was this?
• Well it was a combination of
issues
• Different standing order sets
from our surgeon’s
• The use of multiple antibiotics
prior to surgery
• No consistent method of
informing the unit preparing the
patient of the time patient
would enter the theater

17.
What did we do?
•We standardized order sets
for Colorectal and C-Section
procedures for all surgeons
•We tried multiple PDSAs on
the best method of
communicating when patient
will be entering theater
•We started using surgical
pause to ensure antibiotic
started prior to incision

18.
• We did multiple sets of staff and
physician education on why it was
important to have the antibiotics
delivered within 60 minutes
• We had pharmacy research
appropriate drug administration
rates for the staff so that they could
meet the time requirements with
multiple drugs
• As of Dec 2013 our rate of
appropriate antibiotic prophylaxis is
now 93% and we continue to look at
ways to improve this number.
93
7
Propholactic Antibiotic Rate
Within 60
Minutes
Outside 60
Minutes

19.
Wound Management
• Our final improvement process has
been to trial alternate dressings for
our C-Section patients
• The reason for this is that a C-Section
should never be a dirty procedure
• This surgical category consistently
had our highest rate of Surgical
infections
• The majority of these infections were
superficial infections

20.
• Looking at the indicators for this
procedure it became clear that
two indicators showed up on the
majority of the SSI cases
• The indicators were weight
above 70 KG and removal of
dressing within 24 hours
• As well most of these cases were
discharged home within 48
hours of the procedure
occurring

21.
• Since most of the infections
occurred within 7-10 days of the
procedure what could we do?
• Our current practice at the time
was to apply a standard dressing
and generally remove it at 24
hours
• This wound would then be
cleaned and have a dressing
spray applied
• The patient would then
generally be discharged home

22.
• A search of the current literature
was done as well as discussions
with other health regions
around the province
• What was found was that there
was no set protocol for wound
management within the
literature let alone the province
• Through the search of the
literature what was found was a
dressing that allowed good
mobility, was waterproof and
provided a physical barrier

23.
How could we change this process?
• We could look for a dressing that
stayed intact for a longer time
period
• One that was an active barrier to
bacteria and waterproof so that
it would allow the patients to
have an active lifestyle once
discharged
• A trial of the “Aquacel” dressing
was planned

24.
• One surgeon trialed the dressing while the other two Obstetricians
decided to maintain their current practice
• They provided us with wonderful groups to compare the results
• In the trial group we had 15 surgeries. Out of this group we had 1
infection and this dressing we had difficulties getting proper adhesion
of the dressing.
• In the current practice group we had 17 surgeries and 3 infections.
1
14
Trial Patients
Infections
Total Cases
3
14
Current Practice
Infections
Total Cases

25.
• The difference in the rate between the two surgical groups was 62%
more surgical infections for the current practice.
• Since running this trial we have had a second Obstetrician and a
locum Obstetrician start using this dressing.
• As well we have had interest in our General Surgery program in
starting to use this dressing in our abdominal cases with an open
incision.

26.
What has been the impact of these changes?
• We have had comments from patients:
• “I have never before came out of surgery and been warm”
• “I couldn’t even tell where my incision was as there was no redness
along the spot where they cut”
• “ The dressing allowed me to shower when ever I wanted to once I
got home”

27.
• Staff comments:
• “The dressings are easy to use”
• “The warming device is easy to control and can be turned off once
patient maintains normal temperature in the recovery period”
• “I am seeing good wound bed healing in my office on follow up visits”
• System improvements:
• Noted reduction of C-Section infections in the quarter the dressing
trial was conducted

28.
Cost savings for treatment of each one of
those infections:
• The reduction of at least one
antibiotic prescription
• The reduction of at least one
Physician/Outpatient visit
• Not needing Home Care Services
providing wound care
• Not incurring a readmission
and/or a possible further OR
procedure
• 2 Dollars – 380 Dollars Per
Prescription
• 33.20 Dollars – 230 Dollars Per
visit
• 20 Dollars – 300 Dollars Per visit
• 418 Dollars – 1319 Dollars Per
bed day (not including
treatments)
• All Costs are ranges: actual cost
will vary

29.
Sooner Safer Smarter – Patient First :
• Saving to the patient:
• No Extra lost work time for the patients due to an infection after
surgery
• No costly trips for additional health care services
• No additional stress about the ongoing healing process